Those of us who work in clinical ethics focus most of our intellectual energy on addressing ethical dilemmas in individual cases. Clinical ethics allows little time for armchair reflection. The urgent cases presented to us require fairly quick decisions. That is, if we are to be helpful, we have to find thoughtful ways to analyze ethical questions and reach prudent recommendations. But even for clinical ethicists, it is worthwhile from time to time to take a step back and consider the historical philosophical context in which we work and the challenges it poses for ethical reflection and judgments.

Clinical ethics has been criticized by some not having an adequate basis on which to give substantive answers to pressing ethical questions in medicine. I want to show how this concern is not only, not a problem, but is a sign of progress. First a little background about the state of contemporary western ethics as expressed in one of the most important critiques of philosophical ethics and morality in the past 100 years.

In his 1981 work entitled After Virtue, Alasdair McIntyre claims the actual moral world in which we live is in “a state of grave disorder”. The concepts and terms we use in contemporary ethical discourse, he believes, are nothing more than fragments of prior conceptual schemes that have largely lost their moral import. Even worse, we use ethical discourse in talking about obligation, rights and duties without fully realizing the lost moral orders in which these words once had their original meaning. This is a concerning charge for clinical ethicists since much of our daily work involves using just these kinds of terms. Do we have a clear grasp of what our moral terms mean and how they are being used?

McIntyre describes modern day ethics as being in a moral crisis due to the interminable character of its vocabulary; that is, there is no available rational means by which to secure moral agreement. Moral language finds its only meaning in the theory of emotivism, which was the dominant theory for understanding ethical discourse in the first three decades of the 20th century. Ethical claims, according to this view, have no rational or cognitive meaning; they are only expressions of felt emotions, much like saying “hurrah”. But McIntyre goes on to argue that emotivism reflects the break down and failure of historically predecessor attempts to provide a basis for an objective morality. He argues that by understanding the failure of these predecessor attempts, or what he calls the Enlightenment Project from 1630 to 1850, we can come to grips with the backdrop of our current moral predicament. This is the period during which philosophical attempts to rationally justify ethics, most notably in Kant, failed. These failed attempts followed the traditional Aristotelian framework, which for centuries provided a shared conception between moral rules and precepts and a conception of human nature. In a nutshell, McIntyre is claiming that the Enlightenment Project to replace the ancient Aristotelian moral order, much of which was embedded in the Catholic moral tradition with secular reason, failed. The result in today’s moral setting is that there is no universal moral framework that can provide substantive answers to moral dilemmas such as euthanasia and physician assisted suicide and abortion—questions about the boundaries of human life and the meaning of a good life, not to mention ethical dilemmas in individual clinical cases. But, does McIntyre’s analysis paint the complete picture, and is it really a problem for clinical ethics and bioethics in general?

I agree with McIntyre about lack of a universal moral foundation that would provide universal, substantive moral answers to pressing contemporary ethics problems. But upon further reflection, the failed efforts of what McIntyre called the Enlightenment Project was in fact a quasi-religious attempt to use secular reason to replace religion as a source of moral authority. Most significantly, the period was also the pivotal time during which the conceptual and philosophical understanding of modern democratic systems was emerging and all individuals were being viewed at autonomous moral agents. That is, for the first time in human history, human beings qua citizens, could be seen as having the right to act and live according to their own conscience instead of being bound to the authority of moral authority embedded within a closed society. In such a historical epoch in which the fundamental political order of western life was changing, gradually, toward the acknowledgment of the rights of individual citizens, attempts to find a substantive (religious type authority), universal basis of morality based on reason were destined to fail. That is to say, philosophically, that the job of reason in ethics is no longer to justify ultimate and final answers but to help in the daily, practical work of clarifying the procedural process in which all human beings will better understand their freedoms, rights, responsibilities and obligations. Reaching final moral agreement in today’s world about moral matters of life and death are impossible as McIntyre says; instead, ethics becomes the daily work of discussion, acknowledgment of value differences and the working out of solutions that best fit each situation. But it does not follow that the basis for ethical life is in a crisis, nor does it mean that ethics has been reduced to a crude relativism.

Clinical ethics consultants and bioethicists cannot presume to have final answers to ethical problems. Their task is to work within, or sometimes help design, fair procedural processes in which the value dimensions of modern life can be clarified, so when value conflicts arise, there are viable paths to a resolution. To the religious fundamentalist, or to the philosopher seeking a universal, final answer from secular reason, this conclusion sounds most unsatisfying. But it reflects where we are historically, and I would maintain, it reflects moral progress. Human beings are no longer living in enclosed moral and religious systems in which the good life and moral obligations are defined in advance for them. But nor are they living in a world without moral rules. Ethics, as Aristotle said, is a practical activity in human life. It requires humans to take responsibility for their lives and the values they hold dear that will nurture human flourishing and reduce suffering. Clinical ethicists and bioethicist are crucial to this process, not to assert final answers, but to help reach helpful solutions to human moral conflicts and problems.

The Alden March Bioethics Institute offers graduate online masters in bioethics programs. For more information on the AMBI master of bioethics online program, please visit the AMBI site.